Provider Demographics
NPI:1134426398
Name:CRIVELLI, JUSTIN J (DO)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:J
Last Name:CRIVELLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30575 BAINBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-2221
Mailing Address - Country:US
Mailing Address - Phone:440-542-5000
Mailing Address - Fax:
Practice Address - Street 1:30575 BAINBRIDGE RD
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139
Practice Address - Country:US
Practice Address - Phone:440-542-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2455207R00000X
OH34.010674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1134426398Medicaid